11 OLIVER ST - BUILDING INSPECTION V4 $ i ( l
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The Commonwealth of Massachusetts iNSPECTICBoard of Building Regulations and Standardsl I Massachusetts State Building Code, 780 CM11015OCT ' 011
Building Permit Application To Construct, Repair, Renovate Or Demoli
One-or Tivo-Family Divelling
This Section Far Official Use Onl
Building Permit Number: Date.APalied:
U + Building Official(Print Name). - 3ignattue-: - Date
1 SECTION 1:SITE INFORMATION`
11 Property Address: 1.2 Assessors blap&Parcel Numbers
►1 Oud64-ST
I.I a Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.401§Sq) 1.7 Flood Zane Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesE3
SECTION2: PROPERTYOWNERSHIP�
2.1 OwnerlofRecard: A. A L6r—� I A„� 01-20
jkkNtwA 6l_ou� N E S 'v
� City,S
me(Print) State,ZIP�(Print)
sT Gib � (V S - SSa
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building'' Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief DesPip Ted Work=: 6 MohfitIL Itb H6 ) idB A'r M r
Ko 6 !reoTPfLh-7"
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ J$�0Do a 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S S, CwD ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 3, 000 - k Qther Fees: .S
d. Mechanical (HVAC) 5 List:
5. Mechanical (Fire S Suppression) Total All Fees:S
qq _ Check No.—Check Amount: Cash Amount:
G. Total Project cost: .S tx3 d 0o ❑ Paid in Full ❑Outstanding Balance Due:
rntatt_e:ID \, tb( Zz EFF. Ip/ca lit s
kR vr$\- e 6wh�'�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 0a-) v�R—� �(P
CS -wo 86 1 License Number Expiration Date
Namc of CSL[folder List CSL Type(see below)
Kt5�V l,) QZo la D Type Description
No. and Street -
src%wl � 6 U Unrestricted DuilJin a to 35,000 cu. il.
/1 R Resuicted I&2 F:unil D+vellin
City/roan,Stale,ZIP Q M Masonry
� \�,n�n � I 1 RC RoofingCovering j yg• •R!5 I� / WS Window and Sidin
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Register Home Improvement Contractor(HIC) 103 i �3
I1.-� U L ilt& I IC Registration Numbe E pi ion Date
t C oil :my Name or 11C Registrant Name
� , �, �t.I6ir�lnl()t) w(r'K�t.e CtJm.4•
NZand Street
ZVS 1h c t 01409 11�I b 1�' Email address
Ci /rown, ate ZIP /�W UI Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.94 c.152.$ 25C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Witance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE CONIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
1, as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
jq,k� '.,v1 G I4�6 to -11- u
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
ontained in th' application is true and accurate to the best of my knowledge and understanding.
1C)J 6l o"& 10, 1 4. 15
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will nit have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
Www.mass. •oL +:!OCit Information on the Construction Supervisor License can be found at w+r+v.niuss.no+:'Jns _
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) 'I .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) - Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. Total Project Square Footage"may be eubstimted for"Toed Project Cost"
Y19 <T � �� I
Office of Consumer Affairs&Business Regulation I
,J OMEIMPROVEMENT CONTRACTOR
Iegistration: 183163 Type:
Uxpi Individual � •
XEVIN P ROHDE
— a
:KEVIN :ROHDE tv F
•,22 STETSON AVE
SWAMPSCOTT,MA 01967 Undersecretary
1
A.-M Yhusett..fiN,
ru h Y
Massacs -Department bf Public Safety }
Board.of Building Regulations and Standards
1.Construction Supcn•tsof
` f License CS-027869 {
Kevin ts Rohde - G
22,StetsooAveoue=
Swampscott MA 81
r
• ��� x W`� Expiration
05117f2016
Commissioner
The Cornmonwecltlr ofMgssachuse"'s
Deyr ent oflndumWa1,n4=ents
I Congress Stteey Suite 100
Boston,MA 021I4-2017
www.mau&gov/din
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaas&lumbers.
TO BE FILED WITH THE PERMITTING AUTHORI'M
AoollcantI formation / Please Print IM
Name(Basinesi ftnization/Iomvidnel): "j l_13J3bHi �G,�,J I
Address: q q G L 1 �TD,J ' V--d,f6
ylv C71 L/�
City/State/Zip: �14 tbNars} / Phone#: 7 S 1 77 ) 6-7 )S
Are Yoo m employer?Cbwk the appropriate bor: Type of project(reiluired):
l.pU I am a employera! p1oY�s(fiill end/mpart-tmx).'- 7. Q New Con661ieton
2.Q 1 am a soh pruprietorm paMaahipaod Lave no empkyoes rvotlang forme m 8, IN Realode},ing
coy wpaci7'.[No wakce''eompi.inernmice iequvedJ
9. ❑Demolition'
3.❑1 am a homeowm doing all work mYretf.[No wmkaa•oomp..in.5msnce requved.,)'
4.01m a homeow end will be hiring e®tractm m conduct aU work m my psopoty. I wffi 10 Q Building addlt7
tmtae that all contactors either have workms'compensmon insurenw orare sole 11.Q Electrical repairs or additions
poprimos with nompioyam. 12.�]Pluimbing'iepauscrtidditia s
5.�rem a seaeral commotor and I have hiiW the suD-conRWms listed on me attached sheet. 13.❑Roof repairs
These mb-contractm have employees and have wodara'comp.mmm mt
6.Q We are a corporation and its offioeis have"mised their FWd Ofinemptim per MGL c. 14.QOOnt:r
152,§1(4),and we have no employees.lNo worms'cm¢:iasmence required.I
. *Any applicant that cheeks b=011 must also'at thesietionbelow showangPom works mpobcy m6�atim .
t Homeowners who submit this affidavitindintmgthey arc dorog all work and tbmbne oiitgide tb�atWr must sobma a new affidavit mdiatitg such'.
iConaacmta that check this Boa must attached madditional shad stiowiog dw m&e ofthe sub.comae and state"'tha w.nt those mtiues have
employces. If the sub-contractors have amployees,theYEcust Pwvxlc their workea':aomR Polity Mother .
I am an employer that isproviding workers'compenatuion msrrrm"for my emplgyees. Below,is thepahey andjob site- .
informaBon.
Insurance Company
Policy#or Self-ins.Lic.M - Expiration Date: { �_ - -
Job Site Address: 10 0 Ll V 6(l -St Cit)'/St ) � M,dazip:s G U?�®
Attack a copy of the workers'compensation policy declaration page(showing the policy unmber and mplration date).
Failure to secure coverage as required under MGI,c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imphSdOBMent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of 1 p to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verificatian. ..
I do hereby cc the pains and penabies ofperjary that the information provided above is true and correct
0 -1� lS
Phone
OffWal ase only. Do not write in this area,to he completed by aaly or lows official
City or Town: Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cily/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,
express or irrWhed,oral or written.*'
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an Li.0 or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Depai tnient of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured'companies should ewer their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be'sure to fill in the permit/license number which will be used as a reference number. In addition,an applies=
that must submit multiple pe trut/lieeme applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or cormrercia]venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to corr>blete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
QTY OF SALEA MASSAC HL SEM
BLuDING DEFAmmNr
120 wA9mgGTcNS7REFT,3'DRmR
IkL(978)745-9395,
FAX(978)740.9846
iffiv>BERLEYDRISODI.L
MAYOR 7)ICMAS ST.PIEM
DIRECTORcFFUBLicFRc ERTY/Bu[Dmoomm momR
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54, Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
E'GLl C Z,
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
s ,
ature of applicant
Date
To Whom This May Concern:
This letter is to confirm the owners of 11-13 Oliver St Condo Association are aware of the renovations and
agree to them as described by Akram Elouche, owner of Unit 2.
Property Address: 11 Oliver St Unit 2, Salem MA 01970
Thank you, '
Owner— 11-13 Oliver St Condo Association
t
lo�lc7
Josepff Mi szczyk(It Oliv r St, Unit 1) Date
Mary McC e (1 liver t) Date
PROVIDENCE MUTUAL BUSINESSOWNERS DECLARATION
Policy Penod::
It The Providence Mutual Fire Insurance Company Pohcy Number From To
P.O. Box 6066
Providence, Rhode Island 02940-6066 BOP 0079571 01 06/19/2015 06/19/2016
12:01 A.M.StwWard Time et the dexribW b fi..
Transaction
RENEWAL Direct Bill Nine Payments
Named;Insured and Address: Agent
G7330XS KEVIN J_ DBA ALLAN INSURANCE AGENCY, INC
"IS=S E. SON HOME IMPROVEMENT 63 1/2 JEFFERSON AVE.
AV TUE - PO BOX 511
MA 01945-1760 SALEM, MA 01970
# Telephone: 978-745-5905 0000893
l-;lretamt for payment of the premium, and subject to all the terms of this policy, we agree with you to provide the
r nsa$snce as stated in this policy.
Described Premises: See attached schedule
Business Description: See attached schedule
PROPERTY COVERAGE LIMITS OF INSURANCE:
.................
Buildings See attached schedule
Business Personal Property See attached schedule
Deductible . See attached schedule
Optional Coverages See attached schedule
LIABILITY AND MEDICAL PAYMENTS:
Except for Fire Legal Liability, each paid claim for the following coverage reduces the amount of insurance we provide
during the applicable annual period. Please refer to paragraph D.4 of the Businessowners Liability Coverage Form.
;'his policy contains aggregate limits; Refer to Section D - Liability and Medical Expenses Limits of Insurance for details.
Limits of Insurance
BUSINESS LIABILITY 1,000,000 per occurrence
Products/Completed Operations 2,000,000 aggregate
All Other 2,000,000 aggregate
MEDICAL PAYMENTS 5,000 each person
FIRE LEGAL LIABILITY 100,000 per occurrence
TOTAL POLICY PREMIUM $ 1;064.00
I :Forms and endorsements applicable to all>aocations
B?0501 (07/02) BP0O03 (07/131 BP0108 (03/11) BP0417 (01/10) BP0698 (07/13)
BP0577 (OY/06) BP0517 (01/06) NPBPkAFU (10/10) PMBP13 (10/10) PMBP14 (05/11)
7-3P16 (06/11) BP0419 (07/13) PMBP15 (06/11) BP0704 (01/06) BPNP04 (OS/11)
BP0701 (07/13) BP0453 (07/13) BP0538 (01/15) BP0523 (01/15) BP0515 (01/15)
TD03 (01/15) BP0542 (01/15)
This declaration, together with the coverage form(s), common policy conditions and forms, and endorsements, if any,
issued to form a part thereof, complete the above number policy.
n J
'. Countersigned this Day of _�
Authorized Representative
issued�Date: 04/23/2015 INSURED P
4
TRAVELERSJ
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HUB-2E65853-8-15)
NEW-15
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA NCCICO CODE: 13439
1.
INSURED: PRODUCER:
GIBBONS. I(EVIN J DBA GIBBONS PETER BEATRICE INS AGCY
260 HUMPHREY ST
AND SONS SWAMPSCOTT MA 01907
99 CLIFTON AVE
MARBLEHEAD MA 01945
Insured is AN INDIVIDUAL
Other work places and Identification numbers are shown.in the schadule(s) attached.
2. The policy period is from 01 -20-15 to of-20-16 12:01 A.M. at the insured's mailing address.
3, A. WORKERS COMPENSATION INSURANCE: Part One of the'polIcy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
Rem 3.A. The limits of Our liability under Part Two are:
Bodily Injury by Accident: $ 1 oOo0D Each:Accident
Bodily Injury by Disease: $ 500000 Policy Limn
Bodily.injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, R any, listed here:
.COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
M
SEE LISTING OF ENDORSEMENTS - EJCrENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
p change b audit to be made ANNUALLY.
Plans. All required information Is subject to verification and cha g y
ST ASSIGN: MA
DATE OF ISSUE: 02-03-15 MK
OFFICE: ORLANDO INDUS AFF 161 7376H
PRODUCER: PETER-BEATRICE INS AGCY
COMB